Developing a brief assessment of social risks for the Veterans Health Administration Survey of Healthcare Experiences of Patients

Objective

To determine whether a 6- or 12-month look-back period affected rates of reported social risks in a social risk survey for use in the Veterans Health Administration and to assess associations of social risks with overall health and mental health.

Study Design

Cross-sectional survey of respondents randomized to 6- or 12-month look-back period.

Data Sources and Study Setting

Online survey with a convenience sample of Veterans in June and July 2021.

Data Collection/Extraction Methods

Veteran volunteers were recruited by email to complete a survey assessing social risks, including financial strain, adult caregiving, childcare, food insecurity, housing, transportation, internet access, loneliness/isolation, stress, discrimination, and legal issues. Outcomes included self-reported overall health and mental health. Chi-squared tests compared the prevalence of reported social risks between 6- and 12-month look-back periods. Spearman correlations assessed associations among social risks. Bivariate and multivariable logistic regression models estimated associations between social risks and fair/poor overall and mental health.

Principal Findings

Of 3418 Veterans contacted, 1063 (31.10%) responded (87.11% male; 85.61% non-Hispanic White; median age = 70, interquartile range [IQR] = 61–74). Prevalence of most reported social risks did not significantly differ by look-back period. Most social risks were weakly intercorrelated (median |r| = 0.24, IQR = 0.16-0.31). Except for legal issues, all social risks were associated with higher odds of fair/poor overall health and mental health in bivariate models. In models containing all significant social risks from bivariate models, adult caregiving and stress remained significant predictors of overall health; food insecurity, housing, loneliness/isolation, and stress remained significant for mental health.

Conclusions

Six- and 12-month look-back periods yielded similar rates of reported social risks. Although most individual social risks are associated with fair/poor overall and mental health, when examined together, only adult caregiving, stress, loneliness/isolation, food, and housing remain significant.     

Staff Strategies for Improving HIV Detection Using Mobile HIV Rapid Testing

This paper examines the performance of 13 mobile testing units (MTUs) and rapid HIV testing technology in Los Angeles County as reflected in the relationship between the cognitive strategies used by MTU staff regarding instructions to clients about picking up their test results and returning for test results, and following up with those clients who did not return, and the spatial distribution of MTUs and AIDS rates in 2003. Maps were created using geographic information systems (GIS) data on 93 MTU testing locations and 2003 AIDS cases data. MTU staff (N = 45) were interviewed and several themes were identified. MTU testing locations were clustered near high AIDS rate areas. Staff reports were obtained on 24 clients in the past 6 months who received HIV-negative test results and 24 clients during the same time period who received HIV-positive test results. Staff strategies that were used included keeping clients with them while rapid test results were being processed and adjusting to clients' schedules when arranging for picking up test results. Some staff used tangible incentives such as vouchers for area businesses to encourage preliminary HIV-positive clients to return for confirmatory test results. Staff also sought to convince clients who preliminarily tested HIV-positive to convert from anonymous to confidential testing in order to facilitate clients' linkage to treatment. The GIS findings and client risk data support the Centers for Disease Control and Prevention policy of implementing MTUs and rapid testing in large urban communities with high AIDS rates.     

Patient Preferences for the Management of High-Grade Dysplasia in Barrett’s Esophagus

Surgical esophagectomy, intensive endoscopic surveillance, and mucosal ablative techniques, particularly photodynamic therapy (PDT), have been proposed as possible management strategies for Barretts high-grade dysplasia (HGD). Each option has advantages and disadvantages, and no firm consensus exists for the preferred strategy at this time. The purpose of this pilot study was to gain insight into patient preferences in Barretts HGD management. Twenty patients with Barretts esophagus were enrolled in a questionnaire study. The three possible management options for Barretts HGD including each options potential benefits and harms were presented to the subject in a formalized presentation that was designed to be easily comprehendible by patients. The subjects rated each strategy using a health-related quality of life instrument and chose one of the management strategies assuming they were found to have HGD. The average feeling thermometer rating scale values for the management strategies were as follows: endoscopic surveillance, 79; esophagectomy, 46; and PDT, 60. When asked to choose a strategy, 14 (70%) chose endoscopic surveillance, 3 (15%) chose esophagectomy, and 3 (15%) chose PDT. These findings were statistically significant (P = 0.0024). The patients who chose endoscopic surveillance felt comfortable with endoscopy, while the most common concern about esophagectomy, and PDT was the risk of death and the unknown risk of recurrence, respectively. In summary, when patients with Barretts esophagus were presented with three options to manage HGD, the majority chose endoscopic surveillance. Familiarity with endoscopic surveillance was the predominant reason for the choice.     

Implementation of a Novel Algorithm to Decrease Unnecessary Hospitalizations in Patients Presenting to a Community Emergency Department With Atrial Fibrillation

Objectives

Atrial fibrillation (AFib) is the most common dysrhythmia in the United States. Patients seen in the emergency department (ED) in rapid AFib are often started on intravenous rate‐controlling agents and admitted for several days. Although underlying and triggering illnesses must be addressed, AFib, intrinsically, is rarely life‐threatening and can often be safely managed in an outpatient setting. At our academic community hospital, we implemented an algorithm to decrease hospital admissions for individuals presenting with a primary diagnosis of AFib. We focused on lenient oral rate control and discharge home. Our study evaluates outcomes after implementation of this algorithm.

Methods

Study design is a retrospective cohort analysis pre‐ and postimplementation of the algorithm. The primary outcome was hospital admissions. Secondary outcomes were 3‐ and 30‐day ED visits and any associated hospital admissions. These outcomes were compared before (March 2013–February 2014) and after (March 2015–February 2016) implementation. Chi‐square tests and logistic regressions were run to test for significant changes in the three outcome variables.

Results

A total of 1,108 individuals met inclusion criteria with 586 patients in the preimplementation group and 522 in the postimplementation group. Cohorts were broadly comparable in terms of demographics and health histories. Admissions for persons presenting with AFib after implementation decreased significantly (80.4% pre vs. 67.4% post, adjusted odds ratio [OR] = 3.4, p < 0.001). Despite this difference there was no change in ED return rates within 3 or 30 days (adjusted ORs = 0.93 and 0.89, p = 0.91 and 0.73, respectively).

Conclusions

Implementation of a novel algorithm to identify and treat low‐risk patients with AFib can significantly decrease the rate of hospital admissions without increased ED returns. This simple algorithm could be adopted by other community hospitals and help lower costs.